Basic Information
Provider Information | |||||||||
NPI: | 1750734307 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OPPORTUNITIES INDUSTRIALIZATION CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OIC FAMILY MEDICAL CENTER AT COMMUNITY HEALTH PLAZA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2723 | ||||||||
Address2: |   | ||||||||
City: | ROCKY MOUNT | ||||||||
State: | NC | ||||||||
PostalCode: | 278022723 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2529623450 | ||||||||
FaxNumber: | 2529623451 | ||||||||
Practice Location | |||||||||
Address1: | 1041 NOELL LN | ||||||||
Address2: | MEDICAL PLAZA B | ||||||||
City: | ROCKY MOUNT | ||||||||
State: | NC | ||||||||
PostalCode: | 278042058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2529623450 | ||||||||
FaxNumber: | 2529623451 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2016 | ||||||||
LastUpdateDate: | 12/13/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLACKWELL | ||||||||
AuthorizedOfficialFirstName: | REUBEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2522123480 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | OPPORTUNITIES INDUSTRIALIZATION CENTER, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | NC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.